Doctor Name: | PETER PAUL LACK |
NPI Number: | 1033529987 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | CP00006346 |
Business Practice Address: | 3804 Hastings Ave W Port Townsend, WA - 983689642 |
Business Phone Number: | 3603855505 |
Business Fax Number: | 3603853605 |
Mailing Address: | Po Box 102, PORT TOWNSEND |
State: | WA |
Postal Code: | 983680102 |
Phone Number: | 3603855505 |
Fax Number: | 3603853605 |
NPI Enumeration Date: | 04/30/2014 |
NPI Last Update Date: | 04/30/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TA0400X |
License Number: | CP00006346 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |